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1 ��s��, WELL40ERMIT APPLIGAMN A, M SITE <br /> ,hL— �� MITIGATION <br /> AUG 11 2003 SAN JOAQUIN.000NTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> E;; ,i ?ENT HEAT ?'. 304 E. Weber, Third Floor, Stockton, CA., 95202 f �O„ <br /> Ft'I iTSERVIEr (209) 468-3449 LC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliancewith San <br /> oaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department ,�� <br /> .�/�� n' Assessors <br /> VELL Location lzCll /G' KWI*, E/ _& Cross Street /V�� City SLV � ZjP p Parcel# <br /> 'ROPERTY Owner�//( L�Z/fG/-ll�A' lam%� Address 2 s� 4� S*ft ` City - Tjp !/$q�.,� Phone# <br /> 57 Contractor A'Al/���hJJu-'6�/V�_ePFNV- Address 'y?-7 /1yA� CitY�J 'L 21p�.4�'rdtf9'Z7 Phone# �g <br /> :onsultant/Sub Cntr_f �11/"'Yi Address City Lic# Phone# <br /> ;IS Coordinates:X - y__ , Range Section <br /> YORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> JNEW WELL/BORING(C rr=r'oanB HYDROPUNCH,HANC-AUGER,OTHER') D OVER-BORE <br /> SOIL BORING# -3 PRESSURE GROUT <br /> O W ELL# <br /> Other. Grout Specifications* <br /> ;OMMENTS <br /> YPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING 0 HOLLOW STEM DIA.OF E30REHOLE /s" MULTIPLE CASINGS? O MULTI-LEVEL?a WELL CASING DIA:—A <br /> I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ I/ _TYPE OF CASING: 0 STEEL D PVC 0 OTHER: <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL_- TREMIE TYPE TO BE USED: O AUGERS D HOSE <br /> ]AIR SPARGE I ozone RPUSH POINT GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM <br /> MAXIMUM FREE-FALL DEPTH IS 30') <br /> }'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: i�i."*^-Gl LQ /ia <br /> I OTHER: fl OTHER APPROX.BORING-DEPTH --,oI fS/ D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED if YES,list specifications here): <br /> COMMENTS: / �c.I•✓G Z ,B�-*f`'�S 7V "T- _ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared tKts application and that the work will be done in accordance with San Joaquin <br /> County Ordinanc , Rules and Re lations,and all applicable California Stat Laws. <br /> Signed x Title/Company (// <br /> M - Date <br /> =rintName DEPARTMENT USE ONLY <br /> Aft <br /> 2 _ �P <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �6D <br /> WORKPLAN DATED: n^� 2 <br /> Application Accepted By Date Issued o ` ' —0•••/ � � <br /> Grout Inspection By <br /> Date 0 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY: AID# <br /> PEC DES FEE INFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 2Rd _ 8`1 300 B--II �r2Do . 9�6 <br /> C-5 _ WCC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc_ . <br /> B/29/02 <br />